Provider Demographics
NPI:1063444792
Name:BROCK, LEE R (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:R
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-4234
Mailing Address - Country:US
Mailing Address - Phone:540-891-4444
Mailing Address - Fax:540-891-9034
Practice Address - Street 1:4304 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4234
Practice Address - Country:US
Practice Address - Phone:540-891-4444
Practice Address - Fax:540-891-9034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6398707Medicaid
VABO5224Medicare UPIN
VA6398707Medicaid